Progress in Facilitating National HCV Prevention Miriam J. Alter, Ph.D. Division of Viral Hepatitis Centers for Disease Control and Prevention

Accomplishments During the Past 10 Years Virtually eliminated PT-HCV infection Documented >80% decline in incidence of all new infections Characterized the epidemiology of HCV in the United States Characterized burden of infection and morbidity in the general population WE HAVE A PLAN

HCV Prevention and Control Prevent new infections Prevent and control disease progression Evaluate effectiveness of activities Surveillance and Research MMWR 1998;47 (No. RR-19)

Progress in HCV Prevention and Control Prevent new infections Injection drug users Prevent and control disease progression Evaluate effectiveness of activities Surveillance and Research MMWR 1998;47 (No. RR-19)

Injecting Drug Use and HCV in 2003 Results of Surveillance and Research Harm reduction messages more HCV-specific All drug paraphernalia, not just needles/syringes Cumulative infection rates have slowed 30% prevalence after 2-3 years (vs. 80% in 1989) Incidence remains high 15% annual rate Account for 60% of all new infections

Injecting Drug Use and HCV in 2003 Results of Research and Demos IDUs will accept vaccination Coverage high when offered “on site” HCV-infected IDUs will follow-up with medical referrals Recent, recovering, or occasional IDUs with chronic hepatitis C can be treated successfully Permissive consensus statement on treatment

Progress in HCV Prevention and Control Prevent new infections Prevent and control disease progression Identify, counsel and test persons at risk Evaluate effectiveness of activities Surveillance and Research MMWR 1998;47 (No. RR-19)

HCV Testing Routinely Recommended Based on increased risk for infection Ever injected illegal drugs Received clotting factors made before 1987 Received blood/organs before July 1992 Ever on chronic hemodialysis Evidence of liver disease MMWR 1998;47 (No. RR-19)

HCV Testing Routinely Recommended Based on increased risk for infection Ever injected illegal drugs In high-risk settings identifies 60-70% of HCV positives Received clotting factors made before 1987 Received blood/organs before July 1992 Ever on chronic hemodialysis Evidence of liver disease

Case Control Studies of Acute Hepatitis C United States, 1979-1985 Cases Controls Exposure (prior 6 months) n=148 n=200 Ear piercing 2.7% 3.0% Tattooing 0.7% 0.5% Acupuncture 0 1.0% Incarceration 4.1% 1.0% Military service 1.3% 4.9% Potential exposure known to have occurred before onset of disease Source: JID 1982;145:886-93; JAMA 1989;262:1201-5.

Cross-sectional Studies of HCV Volunteer Patient Groups College Juvenile Exposure Donors GI Spinal VA STD Students Detainees + + NA - + + + NA + + NA + + + + + NA = not applicable Transfusion IDU Nasal drug use Tattooing + - ND ND - - - - ND = not done - - + + + - - - Sources: Conry-Cantilena; Murphy; Balasekaran; Haley; Briggs; Gunn; Hwang; Bair

Cross-sectional or Prevalence Study Exposure and disease outcomes collected simultaneously Identify possible associations requiring further study Temporal sequence of exposure relative to disease unknown Cannot establish association or causal relationship Results not replicated consistently cannot be interpreted as associated with infection

Prevalence of Transfusion or Tattooing and HCV

Average Percent Anti-HCV Positive HCV Prevalence in Selected Groups of Adults by Known or Potential Risk for HCV, United States General population Males Females STD clients Snorted cocaine Tattooed Body pierced Average Percent Anti-HCV Positive

Average Percent Anti-HCV Positive HCV Prevalence in Selected Groups of Adults by Known or Potential Risk for HCV, United States General population Males Females STD clients Snorted cocaine Tattooed Body pierced Average Percent Anti-HCV Positive

Progress in HCV Prevention and Control Prevent new infections Prevent and control disease progression Evaluate effectiveness of activities Surveillance and Research MMWR 1998;47 (No. RR-19)

Evaluation of Screening Criteria Screened HCV Pos. Setting and Criteria No. (%) No. (%) STD clients 3356 (100) 165 (5) IDU (self-report), transfusion <1992 8% 64% IDU (self report, staff assessment), transfusion <1992 12% 70% Plus other (hx STD, age) 63% 97% Incoming prison inmates 1148 (100) 152 (13) IDU 11% 61% IDU, hx liver disease 13% 70% Plus other (ALT, anti-HBc) 27% 91% Source: R Gunn, San Diego; D Burnett, Wisconsin

Progress in HCV Prevention and Control Prevent new infections Prevent and control disease progression Evaluate effectiveness of activities Surveillance and Research Additional guidelines for implementation MMWR 1998;47 (No. RR-19)

Guidelines for Viral Hepatitis Surveillance and Case Management Distributed and available on-line in early 2002 Includes both acute disease and chronic infections Monitor trends in incidence of and risk factors for infection disease Assess burden of disease Identify infected persons requiring counseling and medical follow-up Identify contacts of infected persons requiring counseling and/or post exposure prophylaxis Identify and control outbreaks Demonstration projects to evaluate systems

States reporting registries, 2002 HBV and HCV HBV only HCV only Registry unspecified Pending No registry

Prevention of Viral Hepatitis in Corrections, MMWR Jan. 24, 2003 Immunization for hepatitis A and hepatitis B Counseling and testing for HCV Medical evaluation and management of chronic hepatitis Substance abuse treatment and prevention Release planning for continuity of care and services

Laboratory Guidelines for Anti-HCV Testing Publication in MMWR on February 7, 2003 Establish standardized approach for lab testing and reporting to ensure that a positive report uniformly represents serologic evidence of HCV infection. Expand recommendations to include an option for supplemental testing based on screening test s/co ratios Limits cost while improving accuracy of reported results <5% of high risk persons require additional test Educate regarding performance and interpretation

Progress in HCV Prevention and Control Prevent new infections Prevent and control disease progression Evaluate effectiveness of activities Surveillance and Research MMWR 1998;47 (No. RR-19)